Globbal Implanttolgy Summit 2018 Dr. Niznick’s Lectures On Controversies

Controversies in Implant Connections, Design, Material and Surface Separating Facts from Marketing Rhetoric

Gerald A. Niznick DMD, MSD

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January 2018 CR Surveyed 1120 Dentists using Low Cost Implants 54% Reported using Implant Direct

Gerald A. Niznick DMD, MSD

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Published numerous articles on the Changing Reality of Implant Dentistry Separating Facts from Marketing Rhetoric

Gerald A. Niznick DMD, MSD

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QUESTION: What is best design of the threads; tapered body; cutting groove?

Deeper the threads - less compression; Very tapered - not good in dense bone.

Nobel Replace

ID RePlant

Gerald A. Niznick DMD, MSD

Nobel Active

ID Legacy3

ID InterActive

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QUESTIONS? Effective, self-tapping design of a tapered implant?

A self-tapping implant has a relief and groove that cuts threads in clockwise rotation Relief precedes cutting edge

Relief precedes cutting edge

Straumann Bone Tap

Legacy 2 & 4 


Relief follows cutting edge

BLX Straight Implants: no relief for bone chips-grooves dissecting threads

NobelActive Gerald A. Niznick DMD, MSD

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QUESTION: What companies have contributed to innovations?

Straumann introduced tapered, bone-level implant in 2014, 15 years after Tapered Screw-Vent

1970’s 1970’s

Hollow Basket Screw Implant

1985-1990

1982

1980’s 1-Stage Straight Non Self-tapping

1991-Present

1990-2007 Gerald A. Niznick DMD, MSD

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QUESTION: What companies have contributed to innovations Straumann introduced BLX in 2018 - Copy of Megagen with cutting grooves added 2018 EAO - Viena

Niznick’s First Rule of Implant Design - Widest part of the implant should be at top

BLX

Gerald A. Niznick DMD, MSD

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BLX Implants inserted through 2mm of bone into sinus elevation graft.

Note- once unthreaded, narrow neck submerged, implants lose stability

Unthreade d Narrow Ne ck

Legacy’s Micro-threads engage floor of sinus

Unthreaded Neck inserted into bone

Distal Impl ants in Sinus Pa rallel

Attaching Healing Collars changed angles of implants

Gerald A. Niznick DMD, MSD

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QUESTION? Should the Neck of the Implant Seal the Crestal Opening?
 The theory behind the NobelActive back-taper and V3 Triangle is disproven by these clinical results 16 Legacy3 Implants seal crest at insertion Zero bone loss evident at uncovering

Megagen Design Theory

NobelActive Back-taper

Gerald A. Niznick DMD, MSD

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Theory of MIS V3 Triangular shaped implant neck - leaves more room for bone growth.

Thickness of labial plate is compromised by diameter of final drill, not diameter of Implant MIS’s Seven Implant available in 5 diam. and 6 lengths vs V3 in 4 Diam. and 5 lengths

Seven: 5Diameters and 6Lengths

No justification for V3 flat areas for Immediate placement with graft.

V3: 4Diameters and 5Lengths Round vs Sharp Apex

<3.7

Free final sizing tapered drill unnecessary for preparation of socket in soft bone.

Gerald A. Niznick DMD, MSD

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QUESTION? Do deeper threads increase stability?

Screw-Vent generated 29% more primary stability than NobelActive with deeper threads Tapered Screw-Vent

1.5Deg.

Legacy3

Nobel Active

12Deg. 9Deg.

Tapered Screw-Vent generated 100% more primary stability than Straumann’s Straight Bone-Level implant Gerald A. Niznick DMD, MSD

3.5Deg. 1.5Deg. !70

QUESTION? Is cost of implant directly related to clinical success - NO! Straumann and Implant Direct Implants in the Same Patient - 72.5% Savings 2014 Straumann launched a tapered, bone-level implant

Legacy3 and Straumann bone-level implants in same patient. â&#x20AC;¨ 72.5% Savings based on US List Price

Zirconia: 20Ncm Max. Torque- No Immediate Load $595

Gerald A. Niznick DMD, MSD

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QUESTION: With Nobel promoting Trefoil and Zygoma Implants, is the concept of tipping implants distally to shorten cantilever debunked?

NobelZygoma Implants $517

Gerald A. Niznick DMD, MSD

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QUESTION? What is Optimal in Maxilla - 4 or 6 Implants?

8 Teeth between the Maxillary sinuses SO should be able to place 6 implants

Graphically Placed Implants in Optimal distribution

Gerald A. Niznick DMD, MSD

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QUESTIONS? Micro-threads, Micro-grooves or both?â&#x20AC;¨ Straight or Back-Tapered Coronal Region; slight (2deg.) or extreme (9deg.) taperâ&#x20AC;¨ NobelActive has 9deg. taper with anticlockwise cutting groove.

InterActive has 2deg. Taper with selfNobelActive has back tapered neck tapping vertical cutting groove InterActive sealed crestal opening

Gerald A. Niznick DMD, MSD

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NobelActive Back-tapered Neck with Bone Loss

Gerald A. Niznick DMD, MSD

4.7 Screw Plant

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Sinus Elevation with 3-4mm of Bone for thread engagementâ&#x20AC;¨ Micro-Threads Increase Initial Stability & HA Increases Bone Attachment SEM at 50X of HA Coated ScrewPlant

Bone Graft

Sinus Floor

Micro-threads

Gerald A. Niznick DMD, MSD

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QUESTION: What is better, Round or Sharp Apex?

Sharp apex facilitates change in angle during insertion & can tear Sinus Membrane

Implant Direct InterActive

NobelBiocare NobelActive

Gerald A. Niznick DMD, MSD

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QUESTION? One Shaft Diameter for Reduced Abutment Inventory?

Varying the Diameter Corresponding to Implant Diameter improves emergence profile

Neodent 74Deg. Neodent Abutment

Legacy Abutment

Legacy4 45Deg. Gerald A. Niznick DMD, MSD

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Gerald A. Niznick DMD, MSD

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QUESTION: Should the top part of the implant be textured or smooth?

Implant Direct launches LegacyP in Europe Only ID Launches LegacyP After Niznick Retired

Legacy3 5 Year Study documents 100% Success

Gerald A. Niznick DMD, MSD

Nobel RePlace Available in various neck surfaces, configurations and connections

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QUESTION: Should the Textured Surface Extend to the Top? “The total mean bone level alterations from implant placement through the end of the study was 0.63mm”

Gerald A. Niznick DMD, MSD

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QUESTION? Should the Textured Surface Extend to the Top? 1996 Selective Surface Patent - Zimmer Dental’s Screw-Vent still has this feature

LegacyP with smooth top half LegacyP

Gerald A. Niznick DMD, MSD

Legacy3

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QUESTION: Debate over whether the top part of the implant should be textured Buser Study showed less bone loss when Texture extended into soft tissue “Implants placed with the top of the SLA surface above the bone crest had significantly less bone loss than implants with the top of the SLA surface placed flush with the bone level.”

Gerald A. Niznick DMD, MSD

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QUESTION: What is the best Implant-Abutment Connection?â&#x20AC;¨ Internal won over External, Conical won over Butt Joint

Gerald A. Niznick DMD, MSD

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QUESTION: What is better 45deg. or 78deg. Conical Connection Original Screw-Vent 45deg. lead-in bevel is the most copied connection InterActive (NobelActive)

78deg. Bevel

Implant Direct’s InterActive Nobel Biocare’s NobelActive, Astra + DISADVANTAGES: •

•

•

Legacy Implant (Screw-Vent, Implant Direct’s BioHorizons, MIS) Legacy Zimmer Dental’s 45deg. Bevel Screw-Vent,

Thinner walls increase chance of fracture May require X-Rays to confirm full seating Lowers Internal Hex by 0.8mm limits how short the implant can be.

Gerald A. Niznick DMD, MSD

BioHorizons, MIS +++ ADVANTAGES: •

Thicker walls for strength

•

Easier to confirm full seating

•

Hex closer to top, allowing for shorter implants. !85

QUESTION? Does a longer lead-in bevel provide greater stability - No Internal Conical Won; Morse Taper, Tripod, Butt-joint and External Hex Connections Lost

Metal only make contact in 3 points and to assure that occurs at opening to internal shaft, the Abutment has to be tapered 0.5-1.0 deg. less than lead in bevel.

Neodent “Grand Morse” 74deg. Taper

NobelActive 78deg. Taper

PalTop 68deg. Taper

Gerald A. Niznick DMD, MSD

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QUESTION: What is better - 45Deg. or 74-81deg Lead-in Bevel Screw-Vent/Legacy/BH etc. all 45 Deg. Bevel - Lateral Stability without compromising strength

Astra Implant with 80deg. Lead-in Bevel Restored October 2008

Gerald A. Niznick DMD, MSD

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Astra 80deg. Internal Conical Connection results in thinner (weaker) walls And a deeper wrench-engaging surface that precludes 6mm long implants March 2008

October 2009

October 2009

October 2009

Gerald A. Niznick DMD, MSD

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QUESTION? What is the Ideal Surface? - Textured with soluble blast media Machined and Etched too smooth. TPS (Titanium Plasma Spray) too porous. TiUnite anodized?

TiUnite - Nobel

Gerald A. Niznick DMD, MSD

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QUESTION? What does the published articles say about TiUnite?

Albrektsson- 36 year history of publishing articles promoting Nobel products Albrektssonâ&#x20AC;&#x2122;s Credibility Questionable!

Gerald A. Niznick DMD, MSD

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QUESTION? What did a Periodontist Report on NobelReplace Implants with TiUnite?

“At least 25% of my cases are showing unacceptably high degree of early bone loss.”

Gerald A. Niznick DMD, MSD

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NobelBiocare Introduces “TiUltra Surface” modification TiUnite Rough Surface on the Neck of the NobelDirect Claimed “soft tissue integration”

Gerald A. Niznick DMD, MSD

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NobelBiocare Introduces “TiUltra Surface” modification Anodized Smooth Surface of the Neck of Nobel Implants Claims “mucointegration”

Gerald A. Niznick DMD, MSD

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QUESTION? What is the Ideal Surface? - HA doubled Torque Removal Zimmerâ&#x20AC;&#x2122;s Trabecular Metal midsection reduces critical initial stability Zimmer introduces Trabecular Metal

Gerald A. Niznick DMD, MSD

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Trabecular Metal section slipped over core and apical threads welded on.

The weakness of this weld required FDA recall and change in surgical protocol

Tapered Trabecular Metal Implant Replaced with Straight Design

Changed to Straight Drill leaving no thread engagement apically

Gerald A. Niznick DMD, MSD

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QUESTION?: Any clinical advantage to a more hydrophilic surface?

QUESTION?: Is Straumannâ&#x20AC;&#x2122;s SLActive Surface worth $67 more?

QUESTION?: Any advantage to Roxolid Ti/Zirconium alloy vs Ti6Al4V? Gerald A. Niznick DMD, MSD

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QUESTION?: Does Straumann’s SLActive hydrophilic surface cut healing time from 6-8 weeks to 3-4 weeks and is it worth the $50 extra charge?

Letter to Buser: “The issue is not how much torque it takes to remove an implant in the 3rd-4th week (graphs on right) but how much initial stability can be achieved.”

Tapered Screw-Vent generated 100% more primary stability than Straumann’s Straight Bone-Level implant Gerald A. Niznick DMD, MSD

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Straumann Claims SLActive Advantage is its Hydrophilic Properties Demonstrated by showing blood running up the implant surface - HA and SBM Also

Straumann’s SLActive

Implant Direct’s SBM

Implant Direct’s HA Coated Surface

Gerald A. Niznick DMD, MSD

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QUESTION: Any advantages to Subcrestal Placement? - NO! Ankylos and Bicon Morse Taper (1.5deg.) dictates sub-crestal placement Morse Taper Connection - 1.0-1.5 deg. mating tapers.

Subcortical placement of implant often required for subgingival positioning of abutmentsâ&#x20AC;&#x2122; hight of contour.

Legacy4 Implant placed subcrestal - Dentist used stock healing collar rather than concave Healing Collar in All-in-1 packaging

Ankylos and Bicon Implants have Morse Taper (1.5deg.) Connections

Dentsply Ankylos

Bicon Implants

Subcrestal Placement Sacrificed 2+mm of Crestal Bone Support and complicated abutment attachment Gerald A. Niznick DMD, MSD

The crestal bone prevented full seating of Healing Collar !99

QUESTION: Does platform switching reduces bone loss?

Controlled Study “could not confirm …a reduced peri-implant bone loss” All Conical Connections inset margin

3i External Hex Connection

Gerald A. Niznick DMD, MSD

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Questions: Straight or Tapered Drills for Tapered Implants?

Tapered drills need to be length and depth specific, adding significantly to number of drills Neodent, Division of Straumann - “Each drill is Implant-specific to diameter and depth (i.e. specific to Implant Length and Diameter)

Gerald A. Niznick DMD, MSD

NobelReplace Tapered Implant 4 Diameter Implants/14 Drills

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Use of Straight Step Drills eliminates need for length-specific drills Zimmer’s Screw-Vent and Implant Direct’s implants allow soft-bone/hard bone option Tapered Screw-Vent

Gerald A. Niznick DMD, MSD

ID’s Legacy3

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Question: Self-tapping Implant Design or Use of Bone Taps?

Strength of implant is also critical to whether the implant can be inserted self-tapping in Type 1 & 2 bone Implant Direct Crestal Bone Drills May be Required with Dense Cortical

Gerald A. Niznick DMD, MSD

NobelReplace Surgical Bone Taps Implants are not Self-tapping

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Question: What is Best Material for Dental Implants? Ti6Al4V (ID, Zimmer,BH) Nobel uses Pure Titanium Gr. 4 (because of TiUnite), Straumann uses TiZr Alloy (brittle)

Fracture and Removal of a fractured NobelReplace Implant

Gerald A. Niznick DMD, MSD

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QUESTION: Use of after-market abutments with Nobel and Straumann Implants?â&#x20AC;¨ Both Straumann and Nobel Advise against this to promote sale of their more expensive abutments NobelBiocare discourage use of industry compatible abutments with their implants BUT Nobel now manages Implant Direct so they can share engineering drawings

Fracture of NobelActive more likely due to thin walls from deep bevel and use of weaker CP Ti because TiUnite will not form on stronger Titanium alloy

Gerald A. Niznick DMD, MSD

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Straumann acquired Medentika - is now selling Abutments for competitorâ&#x20AC;&#x2122;s implants NobelBiocare now selling Cad-milled Abutments for competitorsâ&#x20AC;&#x2122; implants

NobelReplace Abutments

Gerald A. Niznick DMD, MSD

Straumann Bonelevel Abutments

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1982-2017 - Gerald Niznick DMD, MSD received 33 US Patents related to Dental Implants “Discovery consists of seeing what everybody has seen, and thinking what nobody has thought” “The greatest obstacle to discovery is not ignorance - it is the illusion of knowledge”

Gerald A. Niznick DMD, MSD

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